Physiology of Normal Labour and Childbirth

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Presentation transcript:

Physiology of Normal Labour and Childbirth 4/24/2017 Physiology of Normal Labour and Childbirth For you assessment you are required to revise those slides with white background. Slides with black ground would give you an idea about few practical aspects of childbirth and care of a woman in labour. http://www.youtube.com/watch?v=duPxBXN4qMg

Parturition Estrogen in late pregnancy: Stimulates production of oxytocin receptors in myometrium. Produces receptors for prostaglandins. Produces gap junctions between myometrium cells in uterus. Factors responsible for initiation of labor are incompletely understood.

Parturition

Parturition Fetal adrenal cortex: Uterine contractions: Chain of events may be set in motion through CRH production. Fetal adrenal zone secretes DHEAS, which travel from fetus and placenta. Uterine contractions: Oxytocin. Prostaglandins.

Labour Pain Variation in pain perception between individuals Why do these different perceptions of pain exist How do midwives respond to different expression of pain Increased reports of pain may indicate complication Culture Personality Past experience Low pain threshold Anxiety Learned behaviour

Pain in Labour C-fibres Uterine smooth muscle A-delta traction and pressure on the peritoneum, uterine ligaments, urethra, bladder, rectum, lumbosacral plexus, fascia and muscles of the pelvic floor Labour pain is the result of many complex interactions, physiological and psychological, excitatory as well as inhibitory. Pain during the first stage of labour is due to distention of the lower uterine segment, mechanical dilatation of the cervix and lastly due to stretching of excitatory nociceptive afferents resulting from the contraction of the uterine muscles1. The severity of pain parallels with the duration and intensity of contraction2. In the second stage additional factors, such as traction and pressure on the parietal peritoneum, uterine ligaments urethra, bladder, rectum, lumbosacral plexus, fascia and muscles of the pelvic floor increase the intensity of pain.

The uterus and cervix are supplied by afferents accompanying sympathetic nerves in the uterine and cervical plexuses, the inferior, middle and superior hypo gastric plexuses and the aortic plexus. The small unmyelinated 'C' visceral fibres3 transmit nociception through lumbar and lower thoracic sympathetic chains to the posterior nerve roots of the 10th, 11th and 12th thoracic and also to 1st lumbar nerves to synapse in the dorsal horn4. The chemical mediators involved are bradykinin, leukotrienes, prostaglandins, serotonin, substance P and lactic acid5. As the labour progresses severe pain is referred to the dermatomes supplied by T10 and L1. In the second stage, the direct pressure by the presenting part on the lumbosacral plexus causes neuropathic pain. Stretching of the vagina and perineum results in stimulation of the pudendal nerve (S2,3,4) via fine, myelinated, rapidly transmitting 'A delta' fibres3. From these areas, the impulses pass to dorsal horn cells and finally to the brain via the spino-thalamic tract

A tool that could be used for pain assessment (Linda Husband-caring for the person with pain in FUNDAMENTAL NURSING PRINCIPLES AND SKILLS 474)

Partograph and Criteria for Active Labor 4/24/2017 Label with patient identifying information Note fetal heart rate, color of amniotic fluid, presence of moulding, contraction pattern, medications given Plot cervical dilation Alert line starts at 4 cm--from here, expect to dilate at rate of 1 cm/hour Action line: If patient does not progress as above, action is required The partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labor. At the alert line, the onset of the active phase of labor (4 cm), the patient is expected to reach full dilation at the rate of 1 cm/hour. At the action line, which is 4 hours to the risk of the alert line, the practitioner is signaled to take action if the patient is not following the expected course of labor.

Clean Delivery Infection accounts for 14.9% of all maternal deaths 4/24/2017 Clean Delivery Infection accounts for 14.9% of all maternal deaths These deaths can be avoided with infection prevention practices Also refer to the HIV set.

Infection prevention practices 4/24/2017 Infection prevention practices Use disposable materials once and decontaminate reusable materials throughout labor and childbirth Wear gloves during vaginal examination, during birth of newborn and when handling placenta Wear protective clothing (shoes, apron, glasses) Wash hands Wash woman’s perineum with soap and water and keep it clean Ensure that surface on which newborn is delivered is kept clean High-level disinfect instruments, gauze and ties for cutting cord These principles apply to all levels of care.

4/24/2017 Support of woman Give woman as much information and explanation as she desires Provide care in labor and childbirth at a level where woman feels safe and confident Provide empathic support during labor and childbirth Facilitate good communication between caregivers, the woman and her companions Continuous empathetic and physical support is associated with shorter labor, less medication and epidural analgesia and fewer operative deliveries Data show that emotional and physical support reduce the complications of labor, such as the need of analgesia and operative interventions. WHO 1999.

Best practices: last stage of labour 4/24/2017 Best practices: last stage of labour Active management of third stage for ALL women: Oxytocin administration Controlled cord traction Uterine massage after delivery of the placenta to keep the uterus contracted Routine examination of the placenta and membranes 22% of maternal deaths caused by retained placenta Routine examination of vagina and perineum for lacerations and injury WHO 1999.

Best Practices: Postpartum 4/24/2017 Best Practices: Postpartum Close monitoring and surveillance during first 6 hours postpartum Parameters: Blood pressure, pulse, vaginal bleeding, uterine hardness Timing: Every 15 minutes for 2 hours Every 30 minutes for 1 hour Every hour for 3 hours

Practices Used for Specific Clinical Indications 4/24/2017 Practices Used for Specific Clinical Indications Bladder catheterization Operative delivery Oxytocin augmentation Pain control with systemic agents Pain control with epidural analgesia Continuous electronic fetal monitoring

Best Practices: Labour and Childbirth 4/24/2017 Best Practices: Labour and Childbirth Use non-invasive, non-pharmacological methods of pain relief during labor (massage, relaxation techniques, etc.): Less use of analgesia OR 0.68 (CI 0.58–0.79) Fewer operative vaginal deliveries OR 0.73 (95% CI 0.62–0.88) Less postpartum depression at 6 weeks OR 0.12 (CI 0.04–0.33) Offer oral fluids throughout labor and childbirth Non-invasive, non-pharmacological pain relief reduces the need for pharmacological/lower dose needed. Neilson 1998.

Lactation Hypothalamus releases PRH. Anterior pituitary releases prolactin: Stimulates milk production. Prolactin secretion primarily controlled by PIH. Oxytocin needed for “milk letdown.”

Lactation Mammary gland: Lobules contain glandular alveoli that secrete milk of the lactating female. Alveoli secrete milk into secondary tubule that converge to form mammary duct. Ampulla: Where milk accumulates during nursing. Neuroendocrine reflex: Act of nursing maintains high levels of prolactin. Sucking may cause release of PRH.

Milk-Ejection Reflex Insert fig. 20.55

Write a short story about oxytocin. This should include: A question which will be certainly in my list of questions this year or next year Write a short story about oxytocin. This should include: History of discovery of oxytocin Its chemistry Its physiological action in childbirth and its other physiological functions Its uses in clinical practice